Quality Control & Assurance Flashcards
7 cards from real Insurance practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Control & Assurance flashcards as text
Which of the following best describes a 'closed-file review' in insurance QA?
Answer: Auditing claim files after they have been fully settled and closed
A closed-file review examines settled claims to assess whether the handling, documentation, and payment decisions were appropriate.
An insurer implements a '100% review' QA approach for newly hired adjusters. This is an example of:
Answer: Universal sampling for high-risk populations
New employees represent a higher risk of errors, so reviewing all of their work (universal sampling) mitigates quality risk until competence is proven.
A QA analyst notices that denial rates are significantly higher for a specific adjuster compared to peers. The BEST next step is to:
Answer: Conduct a targeted file review to determine if denials are justified or erroneous
A targeted review identifies whether the outlier denial rate reflects poor judgment or legitimate pattern recognition before any action is taken.
In insurance quality management, 'Six Sigma' methodology aims to reduce defects to approximately:
Answer: 3.4 per million opportunities
Six Sigma targets 3.4 defects per million opportunities, representing a near-perfect process quality level.
Which of the following is an example of a 'critical error' in an insurance claims QA scorecard?
Answer: Paying a claim for a coverage that was explicitly excluded under the policy
Paying a claim for an excluded coverage is a critical error because it results in direct financial harm and potential regulatory violation.
When an insurance company uses a 'control chart' to monitor claims processing times, the 'upper control limit' (UCL) signals:
Answer: A point at which variation exceeds acceptable process limits and investigation is needed
The UCL on a control chart marks the boundary beyond which a data point suggests the process is out of statistical control and needs investigation.
What is the purpose of a 'QA feedback loop' in an insurance organization?
Answer: To route audit findings back to employees and managers so errors can be corrected and learning applied
A feedback loop ensures that QA findings translate into actionable coaching, training, and process improvements rather than sitting unused in reports.